Medical Exemption Form printable pdf download

Medical Exemption Form

MEDICAL EXEMPTION

Student Name: __________________________________ Birth Date:______________

Parent/Guardian: ________________________________________________________

Address:________________________________________________________________

City:______________________________ State:______________ Zip:____________

Telephone Number: (Home)_____________________ (Work) __________________

Name of School __________________________________Grade__________________

MEDICAL EXEMPTION : As specified in the code of Virginia § 22.1-271.2 C (ii), I

certify that administration of the vaccine(s) designated below would be detrimental to this

student’s health. The vaccine(s) is (are) specifically contraindicated because (please

specify):

________________________________________________________________________

DTP/DT/P: [___]; DT/Td:[___]; OPV/IPV:[___]; Hib:[___]; HBV:[___]; Measles:[___];

Mumps:[___]; Rubella:[___]; Varicella:[___]

This contraindication is permanent: [___], or temporary [___] and expected to preclude

immunizations until: Date (mo., Day, Yr.): ___/___/___.

Signature of Physician/Health Care Provider:___________________________________

Physician/Health Care Provider’s name: _______________________________________

(printed)

Address: ________________________________________________________________

_____________________________________________________________________________________

Telephone: ______________________________________ Fax:___________________

Date (Mo., Day, Yr.): ___/___/___

Medical Exemption Form